Quality Improvement Program Helps Lower Risk of Bleeding, Death Following Stroke

New Initiative Helps Get Vital Clot Dissolving Medication To Stroke Patients More Quickly

New Initiative Helps Get Vital Clot Dissolving Medication To Stroke Patients More Quickly

INTRO: Time is critical after a patient experiences a stroke. If doctors can administer a clot dissolving drug to an eligible patient within 60 minutes after arriving at the hospital, this can be beneficial to recovery. A new study evaluated an initiative designed to improve treatment times for these stroke patients. Catherine Dolf has more in this week’s JAMA Report.

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Gloria walking into exam room

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LOOKING AT GLORIA SCHAFFER NOW, IT’S HARD TO TELL SHE HAD A STROKE ABOUT FOUR MONTHS AGO.

NATSO/FULL Runs:03
“…how many fingers do you see one or two…two…good…”

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SOT/FULL Super@:08 Gloria Schaffer – Stroke Patient Runs:08
“I started feeling the sense like of a strobe light in my eyes. I started seeing flashes, very painful actually.”

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SOT/FULL Super@:16 Gregg C. Fonarow, M.D. – University of California, Los Angeles Runs:08
“Every minute that a blood vessel to the brain is blocked there can be as many as two million brain cells that are dying.”

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tPA drug with syringe, cu of medication bottle, ambulance arriving at hospital, patient being taken out of ambulance

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TISSUE PLASMINOGEN ACTIVATOR OR T-P-A, IS A CLOT DISSOLVING MEDICATION. WHEN GIVEN WITHIN 60 MINUTES OF ARRIVING AT THE HOSPITAL IT CAN HELP DISSOLVE THE CLOT, RESTORE BLOOD FLOW TO THE BRAIN AND LEAVE PATIENTS WITH LESS DISABILITY. THIS TIME FRAME IS KNOWN AS DOOR-TO-NEEDLE TIME. HOWEVER, LESS THAN A THIRD OF STROKE PATIENTS IN THE U-S WERE GETTING T-P-A WITHIN THE 60 MINUTE TIME WINDOW.

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SOT/FULL Super@:44 Gregg C. Fonarow, M.D. – University of California, Los Angeles Runs:14
“The Target: Stroke initiative was designed to improve the timeliness of evaluating patients with stroke, improve their care and hopefully that that would translate to better clinical outcomes.”

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DR. GREGG FONAROW FROM THE UNIVERSITY OF CALIFORNIA, LOS ANGELES AND CO-AUTHORS EVALUATED OUTCOMES AT MORE THAN A THOUSAND U-S HOSPITALS BEFORE AND AFTER THE INITIATIVE WAS ROLLED OUT.

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SOT/FULL Super@1:07 Gregg C. Fonarow, M.D., – University of California, Los Angeles Runs:14
“Just prior to the initiative only 29 percent of patients had door to needle times within 60 minutes. After the initiative was put into place this had increased to 53.3 percent.”

(Video covering 2nd half of bite: IV bag being hooked up)

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JAMA COVER

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THE STUDY APPEARS IN JAMA, JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.

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SOT/FULL Super@1:24 Gregg C. Fonarow, M.D., – University of California, Los Angeles Runs:16
“There was a reduction in mortality, more patients were able to be discharged home, more patients were able to walk on their own and importantly a potential complication that can develop, bleeding into the brain, that was also reduced.”

(Video covering 2nd half of bite: Pan up from floor to doctor and Gloria, Gloria walking, pan up from feet to doctor and Gloria, brain scan

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Gloria and doctor doing hand strength tests

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GLORIA RECEIVED T-P-A WITHIN THE FIRST 60 MINUTES WHICH SHE SAYS HELPED HER RECOVERY.

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SOT/FULL Super@1:45 Gloria Schaffer – Stroke Patient Runs:09
“I did feel better soon after I had the medication. I feel like I got a second chance, a second chance.”

(Video covering 2nd half of bite: Gloria walking into hospital)

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Gloria walking into hospital

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CATHERINE DOLF, THE JAMA REPORT.

TAG:THE TARGET: STROKE INITIATIVE WAS ORGANIZED BY THE AMERICAN HEART ASSOCIATION, AMERICAN STROKE ASSOCIATON AND LAUNCHED IN JANUARY OF 2010.

EMBARGOED FOR RELEASE: 3 P.M. (CT) TUESDAY, APRIL 22, 2014

Media Advisory: To contact Gregg C. Fonarow, M.D., call Kim Irwin at 310-794-2262 or email kirwin@mednet.ucla.edu. To contact editorial author James C. Grotta, M.D., call Alex Rodriguez Loessin at 713-704-1222 or email alex.loessin@memorialhermann.org.
In a study that included more than 71,000 stroke patients, implementation of a quality initiative was associated with improvement in the time to treatment and a lower risk of in-hospital death, intracranial hemorrhage (bleeding in the brain), and an increase in the portion of patients discharged to their home, according to the study appearing in the April 23/30 issue of JAMA, a neurology theme issue.

Intravenous tissue plasminogen activator (tPA; an enzyme that helps dissolve clots) reduces long-term disability when administered early to eligible patients with acute ischemic stroke. These benefits, however, are highly time dependent. Because of the importance of rapid treatment, national guidelines recommend that hospitals complete the evaluation of patients with acute ischemic stroke and begin intravenous tPA therapy for eligible patients within 60 minutes of hospital arrival. However, prior studies demonstrate that less than one-third of patients are treated within the recommended time frame, and that this measure has improved minimally over time, according to background information in the article.

Gregg C. Fonarow, M.D., of the University of California, Los Angeles, and colleagues examined the results of a national quality improvement initiative (Target: Stroke), that was launched to increase timely stroke care. The initiative included 10 key strategies to achieve faster door-to-needle (DTN) times for tPA administration, provided clinical decision support tools, facilitated hospital participation, and encouraged sharing of best practices. This study included 71,169 patients with acute ischemic stroke treated with tPA from 1,030 participating hospitals.

The researchers found that measures of DTN time for tPA administration improved significantly during the postintervention period compared with the preintervention period as did clinical outcomes. The median (midpoint) door-to-needle time for tPA administration for the preintervention period was 77 minutes, which decreased to 67 minutes for the entire postintervention period. Door-to-needle times for tPA administration of 60 minutes or less increased from 26.5 percent to 41.3 percent (and from 29.6 percent to 53.3 percent at the end of each intervention period). Other improvements included in-hospital deaths (9.9 percent to 8.3 percent); discharge to home (38 percent to 43 percent); independence with walking (42 percent to 45 percent); and symptomatic intracranial hemorrhage within 36 hours (5.7 percent to 4.7 percent).

There was also a more than 4-fold increase in the yearly rate of improvement in the proportion of patients with door-to-needle times of 60 minutes or less after initiation of the intervention.

“These findings further reinforce the importance and clinical benefits of more rapid administration of intravenous tPA,” the authors write.

Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

There will also be a digital news release available for this study, including the JAMA Report video, embedded and downloadable video, audio files, text, documents, and related links. This content will be available at 3 p.m. CT Tuesday, April 22 at this link.

In an accompanying editorial, James C. Grotta, M.D., of the Memorial Hermann Hospital, Clinical Innovation and Research Institute, Houston, comments on the two studies in this issue of JAMA regarding improving the time of tPA administration for stroke.

“Whatever benefits occur from interventions to achieve more rapid tPA treatment for patients with acute stroke need to be balanced against the costs to establish and maintain them, both to the payers who will pay for them and the hospital and emergency medical services organizations that will implement and operate them. This issue requires carefully constructed cost-effectiveness studies carried out in the environments where the interventions will be implemented; these are likely to differ between cities in the United States and in other countries and between rural and urban areas.”

“The studies by Fonarow et al and Ebinger et al in this issue of JAMA indicate exactly where and how to direct efforts in improving treatment outcomes for patients with acute ischemic stroke—namely by reducing time from symptom onset to treatment.”

Editor’s Note: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Grotta reported having received consulting fees from Specialists on Call, Frazer, and Stryker and grants from Genentech, Lundbeck, Haemonetics, Covidien, and Zolt.

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